Tips for Shadowing in Healthcare

“Shadowing” is a very powerful method. In a healthcare setting, we can shadow patients or staff to better understand the “current state” of how healthcare is delivered. This allows us to identify waste and opportunities for improvement. We want to see reality rather than make assumptions about how things work – this is the practice of “going to the gemba” (the place where the actual work is done).

One thing I do wherever I go is shadow, to see the experience of the patient and family receiving care, in a medical office.

Why? It doesn't matter what spreadsheets and data “say,” a system works or it doesn't when the customer is receiving the service the way the want, in the shortest amount of time. The only way to know this is to see it first hand. After all, it's what our patients do – they are not consoled by spreadsheets showing good aggregate data when they feel they were just not listened to. See a very sad example of this happening in the slides below.

Ted has posted images of his slides, which include great tips on getting permission from those you are shadowing… showing respect for people rather than invading their gemba. I agree with him that shadowers should not go into the exam room. We're looking for waste, not getting in the way of the value adding work.

Do you have any other “dos” or “don'ts” to share from your shadowing experience? What can you go see today?

I live in the supply chain world working with Value Analysis Teams (the supply side version of Lean Teams) and we always encourage “shadowing customers” on how they use products and services in their respective departments. One Value Analysis Coordinator at a University Teaching Facility tells me that it is difficult for him to Shadow customers for product or service observations because he is the know cost and quality guru in his facility. When he walks into a department he says all of a sudden they are using every product properly in a procedure tray when he is clearly looking for waste in the use of the tray by the clinicians.

A solution that he employs is that he has developed a network of “Shadowers” who work in and around all of the major departments in his hospital to give him the real feedback and information that he is looking. e.g., Procedure Tray – clinicians not using the Drape and the gloves that are in the tray.

Yes, when I work with hospitals, I teach staff members how to shadow their peers instead of doing it myself as the “expert.” It’s far more collaborative and constructive to have a nurse shadowing a nurse or a surgeon shadowing an O.R. nurse alongside another nurse. Staff can create spaghetti diagrams, get input from their colleagues, and identify waste far better since they know the work. You’re teaching them to see it with new eyes. Staff generally aren’t given the time to step back and observe their own work. This leads to a lot of improvement!

I have had some powerful shadowing times in the exam room. It is important to have clear purpose if you go in there though.

Going into the exam room for patients that have to go to clinics for multiple disciplines will show how much care is either duplicated or assumed that the other clinics are handling but nobody adresses.

Another situation was when we found the doctor was doing tasks in the exam room that could be done as external set-up or parallel by the RN. This shadowing led to creating time for the providers to document the visit before moving on to another patient. This led to an improvement in safety and quality.

I always teach that gemba is an oportunity to gain empathy for the patient and their families as well as for those doing the work. While the exam room shadowing is often not needed, there are times it is highly appropriate.

Hey Brian – great point. I was a bit too definitive in my comment. I rarely have staff shadow in the exam rooms because I’m usually helping them get started with Lean. There’s so much opportunity to improve the flow outside of the exam room, there’s less risk of upsetting MDs or other clinicians for “getting in the way.” But there’s definitely a time and a place for gemba observation (and process improvement) in the exam rooms – if it’s welcome by the patients and providers.

If I might add that sometimes you end up learning and shadowing when you don’t even intend to shadow customers such as visiting or taking a loved one to the hospital. In one case we were visiting my wife’s grandmother after she had a cardiac procedure and was in a Cardiac Intensive Care Unit after the procedure. It is amazing what you can observe.

In this case she was in a 2 patient room and the patient beside my wife’s grandmother was being very difficult and had ripped off all of her telemetry package, Electrode Leads, Oxisensor and BP cuff that were vital for her to be monitored on. She was upset and threw them all on the floor which meant that she would require about $30+ worth of new telemetry products to hook her back up. 100% redo on costs on products that would have lasted the total length of this patient’s stay.

Being in the supply chain I often focus on the staff over-using or wasting products needlessly but this visiting a loved one situation really gave me the perspective that it could be the patient’s themselves causing the waste that the staff has no control over. Yet they should have some sort of plan just in case this patient wanted to re-remove her telemetry products additional times.

Good post, Mark. Two notes – 1) I often confront HIPAA being tossed about as a reason why shadowing in patient areas is disallowed, which is, of course, bunk. At some point, it might be helpful to fellow blog followers for you or someone to give tips on how to overcome this reason (excuse?) for disallowing the powerful improvement activity that shadowing is.

2) I surely wish more teaching hospitals would require more shadowing at the fellow level. I assume (yes, risky) that the presumption is that they’re far enough along in their learning to operate on their own. But I just had a friend and seasoned Lean leader encounter a deplorable experience with a fellow that no one witnessed directly to be able to do real-time coaching and possibly salvage what has become a permanent mark in this patient’s mind about the entire healthcare system she’s about to enter.

Shadowing is an incredibly under-rated and under-utilized tool. Kudos for the post.